Book Your Appointment

Appointment Date (mm/dd/year)

Appointment Time

Reason for visit

Clinic  Chino Fontana Rialto

Method of payment  Cash Credit Card Insurance None, state funded program

Insurance Info

If you need an earlier or later appointment please contact the office directly and we will try to accommodate you.

Are you a new patient?  Yes No
Would you like your services to remain confidential?  Yes No
Are you requesting a female provider only?  Yes No

Patient Name (First, Middle, Last)

Date of Birth (mm/dd/year)

Email address (required)

Telephone number (123-456-7890)

If patient is a minor, please complete information below: (Do Not complete if you are a minor requesting family planning services)

Parent / Guardian First and Last Name

Relationship to the patient? Self Mother Father Legal Guardian

Extra Note

We recommend scheduling an appointment, but walk-ins are always welcome. Appointments are scheduled Monday through Friday between the hours of 9:30 a.m. and 5:30 p.m. If you are unable to keep your appointment, please notify our office. If you are having an urgent problem, please inform the receptionist and an appointment will be made as soon as possible. Every effort is made to see patients at their appointed time. Occasionally, consultations last longer than anticipated and emergencies are unpredictable, which may result in an unexpected delay in your appointment. If you need to make an appointment with a specific provider, please make a note for us so we can process it accordingly. We appreciate your patience when these situations arise.